We talk about sex and sexuality

Topic 23: Circumcision

Male circumcision (from Latin circumcidere, meaning “to cut around”) is the surgical removal of the foreskin (prepuce) from the penis. It is estimated that one-third of males worldwide are circumcised. It is most prevalent in the Muslim world (where it is near-universal), parts of Southeast Asia, Africa, the United States and Oceania; it is relatively rare in Europe, Latin America, parts of Southern Africa, and most of Asia. The origin of circumcision is not known with certainty; the oldest documentary evidence for it comes from ancient Egypt. Various theories have been proposed as to how it began, including as a religious sacrifice and as a rite of passage marking a boy’s entrance into adulthood. It is considered religious law in Judaism and established tradition in Islam to circumcise sons.

In modern times, for infants, the procedure is often performed using devices such as the Plastibell, or the Gomco or Mogen-style clamps. The foreskin is opened and then separated from the glans after inspection. The circumcision device (if used) is placed, and then the foreskin is removed. Topical or locally-injected anesthesia may be used to reduce pain and physiologic stress. For adults, general anesthesia is an option, and the procedure is often performed without a specialized circumcision device. A review of literature worldwide found circumcisions performed by medical providers to have a median complication rate of 1.5% for newborns and 6% for older children, with few severe complications. Bleeding, infection, and the removal of either too much or too little foreskin are the most common complications cited. Circumcision does not appear to have a negative impact on sexual function.

Circumcision is controversial. Ethical and legal questions regarding consent and autonomy have been raised over non-therapeutic neonatal circumcision. Some medical associations take the position that the parents should determine what is in the best interest of the infant or child; others state parents are not entitled to demand medical procedures contrary to their child’s best interests, or infringe on the right of the child to make an informed choice for himself when older. Summaries of the views of professional associations of physicians state that none recommend routine circumcision, and that none recommend prohibiting the practice.

For infant circumcision, devices such as the Gomco clamp, Plastibell, and Mogen clamp are commonly used, together with a restraining device. With all these devices, the same basic procedure is followed. First, the amount of foreskin to be removed is estimated. The foreskin is opened via the preputial orifice to reveal the glans underneath and ensure it is normal. The inner lining of the foreskin (preputial epithelium) is bluntly separated from its attachment to the glans. The device is placed (this sometimes requires a dorsal slit) and remains there until blood flow has stopped. Finally, the foreskin is amputated.

For adults, circumcision is often performed without clamps. Non-surgical alternatives such as the elastic ring controlled radial compression device are available.

Pain management

The circumcision procedure causes pain, and perinatal painful procedures have been shown to cause an increase in pain response with later painful procedures, so the use of pain management is advocated. Ordinary procedural pain may be managed in both pharmacological and non-pharmacological ways. Pharmacological methods, such as localized or regional pain-blocking injections and topical analgesic creams, are safe and effective. The ring block and dorsal penile nerve block (DPNB) are the most effective at reducing pain, and the ring block may be more effective than the DPNB. They are both more effective than eutectic mixture of local anesthetics (EMLA) cream, and EMLA is more effective than a placebo. Topical creams have been found to irritate the skin of low birth weight infants, so penile nerve block techniques are recommended for such infants instead.

Non-pharmacological methods such as the use of a comfortable, padded chair and a sucrose or non-sucrose pacifier are more effective at reducing pain than a placebo, but the AAP states that such methods are insufficient to use by themselves, and they should only be used as a supplement to more effective pain management methods. A procedure of shorter duration reduces pain duration; use of the Mogen clamp was found to result in a shorter procedure time and therefore reduced overall pain-induced stress than the use of either the Gomco clamp or the Plastibell.

General anesthesia is an option for adults.

Complications and risks

After reviewing the literature, the American Academy of Pediatrics (2012) found that acute complications “most commonly involve bleeding, infection, or an imperfect amount of tissue removed,” and that “significant acute complications are rare,” occurring in about 1 in 500 newborn procedures in the United States; severe to catastrophic complications were so rare that they were only reported as case reports. The AAP also found it difficult to report an overall complication rate due to scant data on complications, and inconsistencies in how a “complication” was classified across the literature reviewed.

In their review of the medical literature, the American Academy of Family Physicians (2007) found that the complications of infection, bleeding, and failure to remove enough foreskin occur in less than 1% of procedures, and make up the vast majority of all complications. They also found “more serious complications have also occurred,” and that “evidence-based complications from circumcision include pain, bruising, and meatitis.

The American Urological Association (2007) stated that neonatal circumcision is “generally a safe procedure when performed by an experienced operator,” and that although the possibility for serious complications exists, “when performed on healthy newborn infants as an elective procedure, the incidence of serious complications is extremely low.”

The authors of a systematic review (2010) found a median complication rate of 1.5% among neonates, with a range of 0 to 16%. In older boys, rates varied from 2-14%, with a median of 6%. The median risk of serious complications was 0% in both cases.

The American Academy of Pediatrics stated (2012) that “circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction,” and this finding is supported by other reviews. The Royal Dutch Medical Association‘s 2010 Viewpoint mentions that “complications in the area of sexuality” have been reported.

The British Medical Association (BMA) stated in 2006 that circumcision has medical and psychological risks. Hirji et al. (2005) state that “Reports of [. . .] psychological trauma are not borne out in studies but remain as an anecdotal cause for concern.”

Recovery

For infants, the available evidence does not indicate that post-procedure pain management is needed.

Adult circumcisions require four to six weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal.

Effects

Sexually transmitted diseases

There is strong evidence that circumcision reduces the risk of HIV infection in heterosexual men in populations that are at high risk. Evidence among heterosexual men in sub-Saharan Africa shows a decreased risk of between 38 percent and 66 percent over two years and in this population studies rate it cost effective. There is little or no evidence that it protects against male-to-female HIV transmission, and whether it is of benefit in developed countries and among men who have sex with men is undetermined.

Experimental evidence was needed to establish a causal relationship between lack of circumcision and HIV, so three randomized controlled trials were commissioned as a means to reduce the effect of any confounding factors. Trials took place in South Africa, Kenya and Uganda. All three trials were stopped early by their monitoring boards on ethical grounds, because those in the circumcised group had a lower rate of HIV contraction than the control group. The results showed that circumcision reduced vaginal-to-penile transmission of HIV by 60%, 53%, and 51%, respectively. A meta-analysis of the African randomised controlled trials found that the risk in circumcised males was 0.44 times that in uncircumcised males, and that 72 circumcisions would need to be performed to prevent one HIV infection. The authors also stated that using circumcision as a means to reduce HIV infection would, on a national level, require consistently safe sexual practices to maintain the protective benefit.

As a result of these findings, the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that male circumcision is an efficacious intervention for HIV prevention but should be carried out by well trained medical professionals and under conditions of informed consent. Both the WHO and CDC indicate that circumcision may not reduce HIV transmission from men to women, and that data are lacking for the transmission rate of men who engage in anal sex with a female partner. The joint WHO/UNAIDS recommendation also notes that circumcision only provides partial protection from HIV and should never replace known methods of HIV prevention. The Male Circumcision Clearinghouse website was formed by WHO, UNAIDS, FHI and AVAC to provide current evidence-based guidance, information and resources to support the delivery of safe male circumcision services in countries that choose to scale up male circumcision as one component of comprehensive HIV prevention services.

Circumcision has been judged to be a cost-effective method to reduce the spread of HIV in a population, though not necessarily more cost-effective than condoms. Some have challenged the validity of the African randomized controlled trials, prompting a number of researchers to question the effectiveness of circumcision as an HIV prevention strategy.

In addition to the studies which provided information about female-to-male transmission, some studies have addressed other transmission routes. A randomised controlled trial in Uganda found that male circumcision did not reduce male to female transmission of HIV. The authors could not rule out the possibility of higher risk of transmission from men who did not wait for the wound to fully heal before engaging in intercourse. A meta-analysis of data from fifteen observational studies of men who have sex with men found “insufficient evidence that male circumcision protects against HIV infection or other STIs.”

Human papillomavirus

Human papillomavirus (HPV) is a virus that can infect both men and women, and is the most commonly-transmitted sexually transmitted disease. While most HPV infections cause no symptoms and are cleared by the immune system, some types of HPV can cause genital warts, and other types can, if left untreated for years, cause various forms of cancer, including cervical and penile cancer. Genital warts and cervical cancer are the two most common problems resulting from HPV.

Circumcision is strongly associated with a reduced prevalence of HPV infection, meaning that a randomly-selected circumcised man tested for HPV is less likely to be found to be infected with the virus than an uncircumcised man. One analysis by Rehmeyer (2011) found circumcision to be protective against cancer-causing HPV infections specifically, and against the finding of multiple HPV infections. No strong evidence indicates that circumcision reduces the rate of new HPV infection, but circumcision has been found to be associated with increased clearance of the virus by the body, which can account for the finding of reduced prevalence. One analysis by Bosch et al. (2009) found that a man’s being circumcised was associated with, in the female sex partner, a lower risk of both cervical HPV and cervical cancer—especially for women with high-risk partners.

Although genital warts are caused by a type of HPV, there is no statistically significant relationship between being circumcised and the presence of genital warts.

Other sexually transmitted infections

Studies evaluating the effect of circumcision on the incidence of other sexually transmitted infections have reached conflicting conclusions. A 2006 meta-analysis of observational data from twenty-six studies found that circumcision was associated with lower rates of syphilis, chancroid and possibly genital herpes. More recently, a 2010 review of clinical trial data found that circumcision reduced the incidence of HSV-2 (herpes simplex virus, type 2) infections by 28%. The researchers found mixed results for protection against Trichomonas vaginalis and Chlamydia trachomatis, and no evidence of protection against gonorrhea or syphilis. Among men who have sex with men, reviews have found insufficient evidence of an effect against sexually transmitted infections other than HIV, with the possible exception of syphilis.

Phimosis and genital skin inflammation and infections

Circumcision is used therapeutically, as one of the treatment options for balanitis xerotica obliterans, phimosis, balanitis, posthitis and balanoposthitis. An inflammation of the glans penis and foreskin is called balanoposthitis; that affecting the glans alone is called balanitis. Both conditions are usually treated with topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. Although not as necessary as in the past, circumcision may be considered for recurrent or resistant cases. Most cases of these conditions occur in uncircumcised males, and affect 4 to 11% of uncircumcised boys. The moist, warm space underneath the foreskin is thought to facilitate the growth of pathogens, particularly when hygiene is poor. Yeasts, especially Candida albicans, are the most common penile infection, and are rarely identified in samples taken from circumcised males.

Phimosis is the inability to retract the foreskin over the glans penis; authors frequently distinguish between “physiologic” phimosis (or developmental non-retractility) and “pathological” phimosis. The latter is most commonly caused by balanitis xerotica obliterans, for which circumcision is the preferred treatment. The American Medical Association states that circumcision, properly performed, protects against the development of phimosis. Esposito et al. (2008) found topical steroid cream to be a good alternative to circumcision for phimosis, although circumcision is still required for patients where a phimotic ring persists even after steroid cream therapy has been tried.

Urinary tract infections

A urinary tract infection (UTI) affects the parts of the urinary system like the urethra, bladder, or kidneys. There is about a 1% risk of UTIs in boys under two years of age, with the majority of incidents occurring in the first year of life. There is good evidence that circumcision reduces the incidence of urinary tract infections in boys under two years of age; there is fair evidence that the reduction in incidence is by a factor of 3 to 10 times. Circumcision would be most likely to benefit those boys at high risk of UTIs due to anatomical defects.

There is a plausible biological explanation for the reduction in UTI risk after circumcision. The orifice through which urine passes at the tip of the penis (the urinary meatus) has been found to host more urinary system disease-causing bacteria in uncircumcised boys as compared to circumcised boys, especially in boys under six months of age. As these bacteria are a risk factor for UTIs, circumcision is thought to reduce the risk of UTIs through a reduction in the bacteria population.

Cancers

Circumcision has a protective effect against the risks of penile cancer in men, and cervical cancer in the female sexual partners of heterosexual men. Penile cancer is rare, with about 1 case per 100,000 men in developed countries, and higher incidence rates per 100,000 men in sub-Saharan Africa (for example, 1.6 in Zimbabwe, 2.7 in Uganda, and 3.2 in Swaziland). Penile cancer development can be detected in the carcinoma in situ (CIS) cancerous precursor stage, and at the more advanced invasive squamous cell carcinoma stage. Childhood or adolescent circumcision is associated with a substantially reduced risk of invasive penile cancer in particular. Penile cancer has been observed to be nearly eliminated in populations of males circumcised neonatally.

Phimosis (the inability to completely retract the foreskin) and HPV infection are important risk factors for penile cancer, and circumcision mitigates both of them. The mitigating effect circumcision has on the risk factor introduced by the possibility of phimosis is secondary, in that the removal of the foreskin eliminates the possibility of phimosis. This can be inferred from study results that show uncircumcised men with no history of phimosis were not found to be any more likely to have penile cancer than circumcised men. For HPV, circumcision is associated with a decreased prevalence and persistence of cancer-causing HPV infections specifically, and also decreased prevalence of multiple HPV infections, thought to be because circumcision is associated with an increased rate of clearance of HPV by the body.[ Circumcision is also associated with a reduced risk of cervical cancer (which is caused by a type of HPV) in the female partners of heterosexual men, most particularly in the partners of men who engage in high-risk sexual behaviors such as sex starting at an early age, with many partners, and with prostitutes.

Because penile cancer is so rare (and may get more rare with increasing HPV vaccination rates), and circumcision is not without risk, circumcision is not considered to be valuable solely as a prophylactic measure against penile cancer in the United States.

An analysis of study data found “some evidence” of an association between adult circumcision and an increased risk of invasive penile cancer. The authors suggested that this is not due to the circumcision itself causing increased risk for penile cancer, but rather that some men who do get circumcised as an adult are doing so as a treatment for penile cancer, or a condition that is a precursor to cancer.

Prevalence

It is estimated that one-third of males worldwide are circumcised. and it is commonly practiced between infancy and the early twenties. The WHO has estimated that 664,500,000 males aged 15 and over are circumcised (30% global prevalence), with almost 70% of these being Muslim. Circumcision is most prevalent in the Muslim world, parts of Southeast Asia, Africa, the United States, Israel, and South Korea. It is relatively rare in Europe, Latin America, parts of southern Africa, and most of Asia and Oceania. Prevalence is near-universal in the Middle East and Central Asia. The WHO states that “there is generally little non-religious circumcision in Asia, with the exceptions of the Republic of Korea and the Philippines”. The WHO presents a map of estimated prevalence in which the level is generally low (< 20%) across Europe,[ and Klavs et al. report findings that “support the notion that the prevalence is low in Europe”. In Latin America, prevalence is universally low. Estimates for individual countries include Spain and Colombia less than 2%; Brazil 7%; Taiwan 9%; Thailand 13%; and Australia 58.7%.

The WHO estimates prevalence in the United States and Canada at 75% and 30%, respectively. Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West Africa.

Circumcision is (arguably) the world’s oldest planned surgical procedure, hypothesized to be over 15,000 years old, well pre-dating recorded history. There is no firm consensus as to how it came to be practiced worldwide. One theory is that it began in one geographic area and spread from there; another is that several different cultural groups began its practice independently. Peter Charles Remondino suggested that it began as a diminishment of full castration of a captured enemy: castration certainly would have been fatal, while some form of circumcision would permanently mark the defeated, yet leave him alive to serve as a slave.

In the study of the history of circumcision, there are two main “streams” that are followed. One stream is located in the lands south and east of the Mediterranean, and starts with Sudan and Ethiopia, extends through the ancient Egyptians into the Semites, Jews and Muslims, and is picked up by the Bantu Africans. The other stream flows through the Australian Aborigines and Polynesians. There is also evidence that circumcision was practiced in the Americas, but little detail is available about its history.

The Middle East, Africa and Europe

Evidence exists that circumcision was in general practice in the Arabian peninsula in the 4th millennium BCE, and moved into the area that is modern-day Iraq with the Sumerians and the Semites. Our earliest historical record of circumcision comes from Egypt, in the form of an image of the circumcision of an adult carved into the tomb of Ankh-Mahor at Saqqarah, dating to about 2400 to 2300 BCE. No single well-accepted theory has been put forth to explain the significance of circumcision to the Egyptians, but it appears to have been endowed with great honor and importance as a rite of passage into adulthood, done in a public ceremony emphasizing the ideas of the continuation of family generations and fertility. Some theorize it was a mark of distinction for the elite: the sun god Ra was described as having circumcised himself. In addition to possible hygenic reasons, for the purity-obsessed Egyptians circumcision surely concerned purification, and was associated with those committed to spiritual and intellectual development.

Circumcision features prominently in the Hebrew Bible. The narrative in Genesis 17, considered to have taken place around the year 1800 BCE, describes the circumcision of Abraham and Abraham’s relatives and slaves, making Abraham the first named individual to undergo the procedure. In the same chapter, the descendants of Abraham are commanded to circumcise their sons on the eighth day of life. Many generations after Abraham, Moses (traditionally calculated to have lived around 1300 BCE) was raised by the Egyptian elite, so circumcision was doubtless familiar to him. For the Jews of the time, circumcision wasn’t as much a spiritual act as it was physical: it was an outward sign of their covenant with God, and enabled the penis to allow a Jew to fulfill properly the commandment to create offspring. Outside of considering that it was taken up by the Jews purely as a biblical commandment, scholars have suggested that Abraham and his followers adopted circumcision from neighboring cultures as a means to make penile hygiene easier in hot, sandy climates; as a rite of passage into adulthood; or as a form of blood sacrifice.

Alexander the Great the conquered the Middle East in the 4th century BCE, and with him in the centuries that followed came ancient Greek culture and values. The Greeks abhorred circumcision, and this made life for circumcized Jews living among the Greeks (and later the Romans) very difficult. Antiochus Epiphanes (d. 164 BCE) outlawed circumcision, as did Hadrian (d. 138 CE), which led in part to the Bar Kokhba revolt. During this period in history, Jewish circumcision called for the removal of only a part of the prepuce, and some Hellenized Jews attempted to look uncircumcised by stretching the extant parts of their foreskins. This was considered by the Jewish leaders to be such a problem that during 2nd century CE, they changed the requirements of Jewish circumcision to call for removal of every bit of the foreskin, emphasizing the Jewish view of circumcision as intended to be not just the fulfillment of a Biblical commandment, but also an essential and permanent mark of membership in a people.

A narrative in the ChristianGospel of Luke makes a brief mention of the circumcision of Jesus, but the subject of physical circumcision itself is not part of the received teachings of Jesus. Paul the Apostle reinterpreted circumcision into a spiritual concept, arguing the physical one to be no longer necessary. The teaching that physical circumcision was unnecessary for membership in a divine covenant was instrumental in the separation of Christianity from Judaism. Although it is not mentioned in the Quran (early 6th century CE), circumcision is considered essential to Islam, and it is nearly universally performed among Muslims. Circumcision spread across the Middle East, North Africa and Southern Europe with Islam.

Circumcision is thought to have been brought to the Bantu-speaking tribes of Africa by either the Jews or Muslims, the Jews “having settled there after one of the many expulsions from European countries, the Moors settling in North Africa or fleeing from Spain in 1492.” Derek Doyle writes, “It is now accepted by most anthropologists that many of the original inhabitants of today’s Somalia, Sudan, Ethiopia and Abyssinia were people of Semitic and Sumerian origin who came from Arabia.” In the second half of the first millennium CE, some of these people migrated south to contribute to the formation of the Bantu. Tribes were observed to be upholding what was described as Jewish law, including circumcision, in the 16th century. Elements of Jewish ritual, such as dietary restrictions and circumcision, are still found among Bantu tribes.

Aboriginal Australia and Polynesia

Less verifiable evidence exists for the stream of circumcision history dealing with the Australian Aborigines and Polynesians. Our knowledge comes from their oral histories and accounts of missionaries and explorers. For these peoples, circumcision likely started as a blood sacrifice and a test of bravery, and became an initiation rite with attendant instruction in manhood in more recent centuries. The removal of the foreskin was done with seashells, and it is theorized that the bleeding was stopped with eucalyptus smoke.

The Americas

Some groups in the Americas are known to have a history of circumcision. Christopher Columbus found circumcision in practice by the native Americans. It was also practiced by the Incas, Aztecs and Mayans. Theories have been proposed as to how circumcision came to these cultures in the Americas, although none has been considered conclusive.

Modern times: Circumcision as a medical intervention

Circumcision has only been thought of as a common medical procedure since late Victorian times. In 1870, influential orthopedic surgeon Lewis Sayre, a founder of the American Medical Association, began using circumcision as a purported cure for several cases of young boys presenting with paralysis or significant gross motor problems. Circumcision was thought to ameliorate the problems based on a “reflex neurosis” theory of disease with the understanding that a tight foreskin inflammed the nerves and caused systemic problems. The use of circumcision to promote good health also fit in with the germ theory of disease that saw validation during the same time period: the foreskin was seen as harboring infection-causing smegma. Sayre published works on the subject and promoted it energetically in speeches. Contemporary physicians picked up on Sayre’s new treatment and its popularity spread with such publications as such as Peter Charles Remondino‘s History of Circumcision. Circumcision was thought to prevent or cure an enormous and wide-ranging array of medical problems and social ills, including masturbation (considered by the Victorians to be an enormous problem), syphilis, epilepsy, hernia, headache, clubfoot, alcoholism, and gout. By the turn of the century, in both American and Great Britain, infant circumcision was nearly universally recommended.

After the end of World War II, Britain moved to a nationalized health care system, and so looked to ensure that each medical procedure covered by the new system could be demonstrated to be cost-effective. Douglas Gairdner‘s 1949 article “The Fate of the Foreskin” argued persuasively that the evidence available at that time showed that the risks outweighed the known benefits, and subsequently circumcision rates dropped in Britain and Europe. In the 1970s, national medical associations in Australia and Canada issued recommendations against routine infant circumcision, leading to drops in the rates of both of those countries. In the United States, the influential American Academy of Pediatrics has, over the decades, issued a series of policy statements regarding circumcision, sometimes positive, sometimes negative.

An association between circumcision and reduced heterosexual HIV infection rates was suggested in 1986, and then confirmed with the data collected from three large randomized controlled trials in Africa in 2002-2004. Since then, the World Health Organization has been promoting circumcision in high-risk populations.

In the 21st century, circumcision is probably the world’s most widely-performed procedure. It is most often performed for reasons other than medical indication. Circumcision by Muslims for religious purposes, and by Americans for their own preferences, make up the majority of procedures performed today.

There is a long-running and vigorous debate over ethical concerns regarding circumcision in general, and neonatal circumcision for reasons other than intended direct medical benefit in particular. Circumcision is controversial; Alanis and Lucidi (2004) even describe neonatal circumcision as “the world’s oldest and most controversial operation.”

There are three parties involved in the decision to circumcize a minor: the minor as the patient, the parents (or other guardians), and the physician. The physician is bound under the ethical principles of beneficence (promoting well-being) and nonmalfeasance (“first, do no harm”), and so is charged with the responsibility to promote the best interests of the patient while minimizing unnecessary harms. Those involved must weigh the factors of what is in the best interest of the minor against the potential harms of the procedure in coming to a decision.

With a newborn involved, the decision is made more complex due the principles of respect for autonomy and consent, as a newborn is unable to understand or engage in a logical discussion of his own values and best interests. A mentally more mature child can understand the issues involved to some degree, and the physician and parents may elicit input from the child and weigh it appropriately in the decision-making process, although the law may not treat such input as legally informative. Ethicists and legal theorists also state that it is questionable for parents to make a decision for the child that precludes the possibility of a different decision the child may realize later he would have wanted to make for himself. Such a question can be raised for the decision by the parents either to circumcize or not to circumcize the child.

Generally, circumcision on a minor is not ethically controversial or legally questionable when there is a clear and present medical indication for which circumcision is the accepted best practice to resolve the issue. Conditions such as severe phimosis or a preputial tumor are normally treated with circumcision. Where circumcision is the chosen intervention, the physician has an ethical responsibility to ensure the procedure is performed competently and safely to minimize potential harms.

Societally, circumcision is often considered for reasons other than cases of presenting medical need. Public health advocates of circumcision consider it to be a net benefit overall, and therefore feel increasing the circumcision rate to be an ethical imperative. Further, the procedure is advocated during the neonatal period, when it is more inexpensive to perform and has a lower risk of complications. While studies show there is a modest epidemiological benefit to circumcision, critics argue that the number of circumcisions that would have be performed would yield an overall negative public health outcome due to the resulting number of complications or other negative effects (such as pain) relative to the number of urinary tract infections and other health problems averted. Pinto (2012) writes “sober proponents and detractors of circumcision agree that there is no overwhelming medical evidence to support either side.” This type of cost-benefit analysis is higly dependent on the kinds and prevalence of the health problems of the individual population under discussion, and medical consensus regarding how circumcision affects those health problems.

Parents are assumed to have the child’s best interests in mind. Ethically, it is imperative that the medical practitioner inform the parents about the benefits and risks of the procedure, and obtain informed consent before performing it. Practically, however, many parents come to a decision about circumcizing the child before he is born, and a discussion of the benefits and risks of the procedure with a physician has not been shown to have a significant effect on the decision. Some parents request to have their newborn or older child circumcised for non-theraeputic reasons, such as the parents’ desires to adhere to family tradition, cultural norms or religious beliefs. In considering such a request, the physician may consider (in addition to any potential medical benefits and harms) such non-medical factors in determining what are the child’s best interests, and may ethically perform the procedure. Equally, without a clear medical benefit relative to the potential harms, a physician may take the ethical position that non-medical factors do not contribute enough as benefits to outweigh the potential harms, and refuse the perform the procedure. Medical organization such as the BMA state that their member physicians are not obligated to perform the procedure in such situations.

Cultures and religions

In some cultures, males must be circumcised shortly after birth, during childhood, or around puberty as part of a rite of passage. Circumcision is commonly practiced in the Jewish and Islamic faiths.

Jewish religious law states that circumcision is a mitzva aseh (“positive commandment” to perform an act) and is obligatory for Jewish-born males and for non-circumcised Jewish male converts. It is only postponed or abrogated in the case of threat to the life or health of the child. It is usually performed by a mohel on the eighth day of life in a ceremony called a brit milah (or Bris milah, colloquially simply bris), which means “Covenant of circumcision” in Hebrew. According to Jewish law, the foreskin should be buried after a brit milah. The rite is considered of such importance that in Orthodox communities, the body of an uncircumcised Jewish male will sometimes be circumcised before burial. Although 19th century Reform leaders described it as “barbaric”, the practice of circumcision “remained a central rite”[ and the Union for Reform Judaism has, since 1984, trained and certified over 300 practicing mohels under its “Berit Mila Program”. Humanistic Judaism argues that “circumcision is not required for Jewish identity.”

The Igbos of Nigeria also traditionally practice circumcision of infants on the 8th day. This tradition in particular has historically been cited as evidence of a link between the Igbos and the Jews.

In Islam, circumcision is mentioned in some hadith (it is referred as Khitan), but not in the Qur’an. Some Fiqh scholars state that circumcision is recommended (Sunnah); others that it is obligatory. Some have quoted the hadith to argue that the requirement of circumcision is based on the covenant with Abraham. While endorsing circumcision for males, Islamic scholars note that it is not a requirement for converting to Islam.

The Roman Catholic Church formally condemned the ritual observance of circumcision and ordered against its practice in the Ecumenical Council of Basel-Florence in 1442. The Church presently maintains a neutral stance on circumcision as a medical practice.

Circumcision is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches. Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya, require circumcision for membership. Some Christian churches celebrate the Circumcision of Jesus. The vast majority of Christians do not practise circumcision as a religious requirement.

Circumcision in South Korea is largely the result of American cultural and military influence following the Korean War.

In some African countries, male circumcision is often performed by non-medical personnel under unsterile conditions. Circumcision is part of initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land, where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago. Among some West African groups, such as the Dogon and Dowayo, circumcision is taken to represent a removal of “feminine” aspects of the male, turning boys into fully masculine males. Among the Urhobo of southern Nigeria it is symbolic of a boy entering into manhood. The ritual expression, Omo te Oshare (“the boy is now man”), constitutes a rite of passage from one age set to another.[ In West Africa infant circumcision may have had tribal significance as a rite of passage or otherwise in the past; today in some non-Muslim Nigerian societies it is medicalised and is simply a cultural norm.

Economic considerations

The cost-effectiveness of circumcision has been studied to determine whether a policy of circumcising all newborns, or a policy of promoting and providing inexpensive or free access to circumcision for all adult men who choose it, would result in lower overall societal healthcare costs. As HIV/AIDS is an incurable disease that is expensive to manage, significant effort has been spent studying the cost-effectiveness of circumcision to reduce the spread of HIV in the many parts of Africa that have a relatively high HIV infection rate and low circumcision prevalence. Several analyses have concluded that HIV-prevention circumcision programs for adult men in Africa are cost-effective, and in some cases are cost-saving. In Rwanda, circumcision has been found to be cost-effective across a wide range of age groups from newborn to adult, with the greatest savings achieved when the procedure is performed perinatally due to the lower cost per procedure and greater timeframe for HIV infection protection. Circumcision for the prevention of HIV transmission in adults has also been found to be cost-effective in South Africa, Kenya and Uganda, with cost savings estimated in the billions of US dollars over 20 years. Hankins et al. (2011) estimated that a $1.5 billion investment in circumcision for adults in 13 high-priority African countries would yield $16.5 billion in savings.

The overall cost-effectiveness of neonatal circumcision has also been studied in the United States, which has a significantly different cost setting as compared to Africa in areas such as public health infrastructure, availability of medications, and medical technology and the willingness to use it. A study by the Centers for Disease Control and Prevention (CDC) suggests that perinatal circumcision would be societally cost-effective in the United States based on circumcision’s efficacy against the heterosexual transmission of HIV alone, without considering any other cost benefits. The American Academy of Pediatrics (2012) recommends that neonatal circumcision in the United States be covered by third-party payers such as Medicaid and insurance. A Johns Hopkins study (2012), taking into account all the reported benefits of circumcision such as reduced risks from HIV, HPV, HSV-2 and UTIs, calculated that if the circumcision rate in the United States were to drop from 55% to 10% (the rate in Europe), it would “increase lifetime health care costs by $407 per male and $43 per female.” The overall costs of the circumcision procedure are significantly more expensive for an older male than a newborn.

After hospital circumcision, the foreskin may be used in biomedical research, consumer skin-care products, skin grafts, or β-interferon-based drugs.

Positions of medical associations

Australasia

As of 2010, the Royal Australasian College of Physicians state: “After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. However it is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons.”

Canada

The Canadian Paediatric Society’s “Caring for Kids” website (updated 2004) states that infant circumcision is not medically necessary, and that parents interested in circumcision for societal, cultural or religious reasons should first speak with their son’s pediatrician to learn about the risks and benefits of the procedure. The Society does not recommend routine circumcision for all infant males.

The College of Physicians and Surgeons of British Columbia (CPSBC) Professional Standards and Guidelines for surgeons (2009) describes circumcision as “medically unnecessary” and “cosmetic” rather than prophylactic as, in their view, the benefits do not outweigh the risks, and that routine circumcision for all infant males is not recommended. They describe the preference of the parents as “important” but recommend that surgeons discuss the risks and benefits with the parents. The CPSBC states that in Canada, the procedure is “assumed to be legal if it is performed competently, in the child’s best interest, and after valid consent has been obtained,” but that there are ethical and legal arguments regarding parental proxy consent, and that surgeons are not obliged to perform the procedure.

Finland

The Finnish Medical Association opposescircumcision of infants for non-medical reasons, arguing that circumcision does not bring about any medical benefits and it may risk the health of the infant as well as his right to physical integrity, because he is not able to make the decision himself. The association emphasizes that according to the Finnish constitution, the parents’ freedom of religion and conscience does not produce the right to violate other people’s (children’s) right to physical integrity.

Germany

In Germany, in 2008, the German Association for Pediatric Surgery cautioned surgeons against allowing the ordering of the procedure for what could appear to be non-medical reasons.

International

The World Health Organization and UNAIDS (2007) recommend considering circumcision as part of a comprehensive program for prevention of HIV transmission in areas with high endemic rates of HIV.

The Netherlands

In the Netherlands, the Royal Dutch Medical Association (KNMG) stated in 2010 that non-therapeutic male circumcision “conflicts with the child’s right to autonomy and physical integrity.” They called on doctors to inform caregivers seeking the intervention of the (in their assessment) medical and psychological risks and lack of convincing medical benefits. They stated that there are as good reasons for legal prohibition of male circumcision as exist for female genital mutilation (FGM).

United Kingdom

There is a spectrum of views within the BMA’s membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. Moreover, the Association states that “there is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research.” As a general rule, the BMA believe that “parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices.” They also state that “both parents […] must give consent for non-therapeutic circumcision”, and that parents and children should be provided with up-to-date written information about the risks involved.

The BMA state that parents should be informed about the lack of consensus within the medical profession with regard to the potential health benefits of non-therapeutic circumcision, adding that they consider the evidence for such benefits to be insufficient as the sole reason for carrying out a circumcision.

United States

In a 2012 position statement, the American Academy of Pediatrics (AAP) stated that a systematic evaluation of the medical literature shows that the “preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure” and that the health benefits “are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns,” but “are not great enough to recommend routine circumcision for all male newborns”. The AAP takes the position that parents should make the final decision about circumcision, after appropriate information is gathered about the risks and benefits of the procedure. The 2012 statement shows a shift in the AAP’s position from their 1999 statement in that the AAP says the health benefits of the procedure outweigh the risks, and supports having the procedure covered by insurance.

In 2011, the AMA released policy statements that parents should be given the opportunity to make an informed choice regarding circumcision for their infant sons, and opposing attempts to make circumcision illegal.

The American Academy of Family Physicians (2007) recognizes the controversy surrounding circumcision and recommends that physicians “discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son.”

The American Urological Association (2007) stated that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks, stating that “while the results of studies in African nations may not necessarily be extrapolated to men in the United States at risk for HIV infection, the American Urological Association recommends that circumcision should be presented as an option for health benefits. Circumcision should not be offered as the only strategy for HIV risk reduction. Other methods of HIV risk reduction, including safe sexual practices, should be emphasized.”